Cate Campbell has spent most of her professional swimming career trying to find a way to manage her periods.
And through that process, she's discovered what can go wrong without access to the right information or women's health professionals.
"We are so precise about every other aspect of our training, from our physical to our mental health, to our nutrition to our recovery," Campbell told ABC Sport.
"Why is this an area that has been neglected for so long?"
'Didn't feel like myself' on the pill
The four-time Olympic champion experienced "patchy" periods which would often appear during competitions, and her weight would fluctuate during her menstrual cycle.
In 2012, she reached out to Swimming Australia for help and was advised to talk to her gynaecologist, who prescribed her the pill.
"I had a really bad experience with that — I put on five kilos, I felt foggy, I didn't feel like myself," Campbell said.
"Over the year that I was on it, I could say that I was slipping into a bit more of a depressed state, which I know a lot of women talk about."
Campbell came off the pill and started talking to fellow swimmers about how they managed their periods.
They recommended a progesterone-only bar which sits inside the arm.
She had it inserted in 2018, but it didn't work for her, so went back to her GP to have it removed soon after.
"And that's where we ran into some real trouble," Campbell said.
The bar is supposed to sit in the fat layer in the arm that's above the muscle and underneath the skin.
But because of her low body fat percentage, the bar had been inserted against her muscle.
"[My GP] didn't know this at the time, so she could feel it and she was trying to dig around for it.
"She was digging and digging and kept on hitting the ulnar nerve."
Campbell had to get the implant removed by a surgeon, who advised her the experience was common for people with low body fat.
The bungled initial retrieval left her with serious bruising and permanent nerve damage.
“I have a strange sensation in my pinkie finger and through my palm during times where I'm in very heavy training load that can turn to tingling and numbness," she said.
"It affects my ability to hold things, which then affects my ability to lift heavy weights in the gym.
"I just feel like throughout that whole course, there was no expert who I could turn to. There was no referral network.
“I decided to do this through word of mouth because it wasn't something that was really spoken about within the broader sporting community."
The 30-year-old now uses the Mirena IUD.
"It's not a perfect solution. It gives me some very intense cramps around the time of my period, but my period is very light, and only comes once every two months," she said.
"So I can't specifically manage when it is, but I find that it's easier than going through a regular cycle.
"I can't wait for the day when we find a side-effect-free form of hormonal contraception."
Learning about women's bodies
Campbell's experience is something Swimming Australia hopes to change through a partnership with City Fertility.
Tiarna Ernst is a former AFLW player and fertility specialist with City Fertility.
She came up with the idea to provide athletes with access to the group's network of women's health experts, and create an online platform with educational resources.
And with only an estimated 6 per cent of research in exercise and sports literature based on female athletes, the goal is to increase expertise in the area as well.
"We actually don't know a lot about the female body," Dr Ernst told ABC sport.
"And potentially how the changes and the unique circumstances within the female body both with the menstrual and ovarian hormones, but also pregnancy, can impact upon how athletes are behaving on and off the field, from a risk of injury as well as performance."
Dr Ernst stressed the need to recognise that there is no one-size-fits-all approach.
"Playing AFLW at the highest level for five years, I found that when I was on my period, I felt like my uterus was falling out," she said.
"I would have lots of cramps, and I found it difficult to concentrate on and off the field."
She used hormonal contraceptives to manage her periods and wants others to have access to the same information as she had.
"So that we can make sure that we have everyone performing the best they possibly can and not missing time away from training and competition, if that's causing them such significant concerns."
Greg Shaw is Swimming Australia's General Manager — Performance Support, and says it's important the resources developed in the partnership are available to swimmers at all levels.
"There isn't a normal and there's so much individuality to reproductive health," he said.
"It's exposing ideas to make people feel comfortable to talk about these things as barriers to performance, rather than things that as a female athlete, you need to suffer through on the side of your athletic career."
'You're not crazy, it is real'
Paralympian Katja Dedekind experienced extremely painful periods from the time she started menstruating.
But like so many women, it wasn't taken seriously.
"I was told for years that it was in my head and that I was imagining it," she told ABC Sport.
The 21-year-old was finally diagnosed with severe endometriosis several years ago.
On average, the disease takes 7–10 years to be diagnosed from the time symptoms start.
"It just made me cry with happiness that it was real because I wasn't going crazy," Dedekind said.
"Now I just push for everyone to go get some form of check. You can get scanned, you can get surgeries, you can get different pills that can help manage pain.
"You're not crazy, it is real, and it can be helped in some way."
While Dedekind has found a supportive doctor who she credits with helping her, she still experiences serious pain and consistent bleeding.
"I have struggled with this chronic illness for so long, and you think you get on top of it, and then it just gets worse.
"I am sad to say that I haven't learned a way to manage it properly."
Like Campbell, Dedekind wants to see more research dedicated to women's health, to help understand conditions like hers, and many others.
"There's definitely not enough knowledge of every chronic illness or illness that has to do with the female body and that's just in everyday life, never mind how it affects your sporting body and how you race, train and recover," she said.
"It's really hard to have the support that we need when there's not all that much knowledge about it."
Dr Ernst agreed the level of education around menstruation was low amongst athletes, support staff, and coaches.
"There'll be a lot of athletes out there that are suffering in silence and just thinking that it's okay to suck it up and battle through period pain," Dr Ernst said.
"We need to try and increase the education and awareness at all levels of women's sport."
Eliminating the taboo
Campbell has started to see improvements in awareness.
"[I want to see] more open discussion about periods and hormones and female health on the pool deck, just something that's normalised," Campbell said.
"I was very lucky, my coach was very open to talking about it.
"But just because of the broader societal culture of silence around this topic, I often didn't feel comfortable raising it with him."
Dedekind has also urged coaches to listen to their athletes.
"You may think they're just trying to get out of laps, but at the end of the day, you can actually see it when a person is being genuine.
"We can educate people, this is actually a thing, this is a symptom of it, if this person isn't getting help, this is how you can help them."
Greg Shaw agreed.
"It's important to be aware that each individual athlete has unique challenges from a female health perspective," he said.
"And our job, as coaches and professionals, is not to diagnose and treat, but rather to identify and be able to point them in the right direction for additional support."
